Biotechnology & Biotechnological Equipment

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Lichenoid Reactions Due to Dental Restorative

Materials

M. Cekova, A. Kisselova & N. Yanev

To cite this article: M. Cekova, A. Kisselova & N. Yanev (2010) Lichenoid Reactions Due to
Dental Restorative Materials, Biotechnology & Biotechnological Equipment, 24:2, 1874-1877, DOI:
10.2478/V10133-010-0035-1

To link to this article: https://doi.org/10.2478/V10133-010-0035-1

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Published online: 15 Apr 2014.

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 Article DOI: 10.2478/V10133-010-0035-1 MB

LICHENOID REACTIONS DUE TO DENTAL RESTORATIVE MATERIALS

M. Cekova1, A. Kisselova1, N.Yanev2
1
Medical University Sofia, Faculty of Dental Medicine, Department of Oral Diagnostics and Maxillofacial Radiology,
Sofia, Bulgaria
2
University Specialized Hospital for Maxillofacial Surgery, Sofia, Bulgaria
Correspondence to: Maria Cekova
E-mail: mpcekova@abv.bg

ABSTRACT
The pathogenic relationship between the oral lichenoid reaction and dental restorative materials has been confirmed many times.
Lichen planus-like lesions (2) (oral lichenoid lesion,oral lichenoid reaction) can be caused by hypersensitivity to materials for
dental restorations.
The aim of this study is to determine the effect of restorative dental materials removal on the lichenoid reaction development. In this
case report we present two male patients who were referred to the Department of Oral Diagnostics and Maxillofacial Radiology,
at the Faculty of Dental Medicine, Medical University Sofia. Both patients had lesions located on the tongue and buccal mucosa.
The routine examinations together with patch tests for dental allergy were used. The patients showed hypersensitivity to Nickel
(Ni), Cobalt (Co), Amalgam and Mercury (Hg). Removal of the positively reacting materials followed by new hypoallergenic
restorations led to spontaneous healing.
The results have shown that the removal and replacement of these restorative materials do lead to remission of the symptoms and
full healing of the oral lichenoid lesions. Close association between the lesion development and the dental materials which gave
positive patch tests reaction was confirmed. A replacement of the problem causing restorations with hypoallergenic materials
proved to be the reliable method for controlling the clinical symptoms and also led to a state of total healing of these two patients.
Biotechnol. & Biotechnol. Eq. 2010, 24(2), 1874-1877 or allergic effect, though dental restorative materials must
Keywords: Oral Lichen Planus, Oral Lichenoid Lesion, satisfy strict biocompatibility specifications (13).
Contact Allergy, Dental Materials, amalgam fillings These oral lichenoid lesions included striated, reticular,
plaque-like, erythematic, erosive, vesicular, and ulcerative
Introduction forms. Patients’ complaints were of soreness, itching, an
Dental restorative materials (metals, amalgam, resins, etc.) unpleasant metallic or battery taste, or pain (3).
may cause contact allergy reactions in the mouth with The other clinical signs of contact hypersensitivity in
different clinical presentation. There are many reports in the the mouth vary from senses of “burning”, pain, dry mouth
literature where oral lichenoid lesions could be provoked by (burning mouth syndrome) (12) to quite obvious features of
hypersensitivity to dental restorative materials (6, 7) When lichenoid reactions on the buccal mucosa, tongue and lips. Our
the terms Oral lichen planus (OLP) and Oral lichenoid lesions goal was to define:
(OLL) are used with same meaning by some authors, it is 1. The clinical features of the oral lichenoid reaction
quite confusing. OLP is a chronic autoimmune disease, which present;
affects the oral mucosa and presents with Wickam‘s striae. 2. To evaluate the healing process after replacing the
Genesis of OLL (lichen planus like lesion) has not been an restorations with hypoallergenic ones.
autoimmune one but can mainly be provoked by a contact
hypersensitivity to amalgam and other dental materials and Materials and Methods
medication. OLP is an autonomic disease but often can develop Two male patients 55- and 60-year old with lichenoid lesions
from already existing OLL in the presence of some dental on the tongue and the buccal mucosa (Fig. 2) were investigated
substance. Histopathologically OLP and OLL have similar and treated (Fig. 1, Fig. 3).
features. The diagnosis of OLP is always made by clinical and Both of them were non smokers with modest alcohol usage
histopathological investigation. The diagnosis of OLL can be (about 50-100 ml daily). The patients were referred to the
given only by its clinical appearance. It is important that oral Faculty of Dental Medicine, Department of Oral Diagnostics
lichenoid reaction always disappear after the amalgam fillings and Maxillofacial Radiology and gave their written informed
are removed. Oral lichenoid reaction has often been reported in consent. Both patients met the basic criteria:
middle aged females than males. - dental restorative materials in close proximity to the
In dental practice the oral lesions of such origin are lesions;
common. Local inflammation is often due to the toxic, irritant - not having any autoimmune diseases;
1874 Biotechnol. & Biotechnol. Eq. 24/2010/2
 - not using drugs known to cause similar reactions.
Fig. 1. Severe lichenoid reaction on the mucosa of the tongue- ventral view
Fig. 2. Lichenoid reaction on the right side of the tongue and on the buccal
mucosa
Fig. 3. Severe lichenoid reaction on the mucosa of the tongue- dorsal view
Both patients reported sensitivity and discomfort of the oral
mucosa, roughness of the tongue and xerostomia.
None of them had any skin lesions.
The first patient, 55-years old male, had nickel consisted
fixed metal prosthesis, 3 resin composite fillings and 1 acryl
Biotechnol. & Biotechnol. Eq. 24/2010/2
partial denture. The other patient, 60 years old, had 4 amalgam
fillings and 1 acryl partial denture.
Screening patch tests for dental materials (mercury,
amalgam, methyl-metacrylate-MMA, nickel sulphate, cobalt
chloride) as well as photographs were taken.
Routine patch tests chambers of allergens were
implemented. Standard testing substances (Chemotechnique
Diagnostics, Sweden) authorized by the ICDRG (International
Contact Dermatitis Research Group) were used to determine
contact hypersensitivity to the dental restorative materials. A
small amount of each allergen (placed into a chamber) was
applied on to the skin of the back for a period of 48 hours and
fixated by hypoallergenic plaster to ensure close contact with
the skin.
Based on the medical history and the clinical examinations
a diagnosis of lichenoid changes in the oral cavity was made.
All materials in the oral cavity which gave allergic test
reactions were replaced with tested materials which did not
show any allergic reactions.
The patients took part in the study after giving a written
informed consent according to the guideline of the ethics
committee.
Results and Discussion
The results were read 30 min after removing the chambers
from the back. The system marks are as follows: (-) negative,
(?) doubtful, (+) weak reaction, (++) strong reaction, (+++)
extreme reaction. Both patients gave strong positive reactions
(Fig. 4). The 55-year old patient had a dry mouth and pain for
about two months since his new restorations were placed. He
showed positive patch tests for materials included in the resin
and the methacrylate dental materials, Nikel sulfate, CO. The
60-year old male also suffered from such a reactions after his
dental treatment. He showed positive patch tests for mercury,
amalgam fillings, and MMA.
A replacement of the dental restorative materials (amalgam
fillings, nickel consisting bridges and crowns, MMA, resin
composite) was suggested. Lesions healed or improved
significantly, and symptoms resolved, in both patients after
replacement of their restorations. In the following 3 weeks
the lichenoid lesions showed quick remission and in about 2
months healed completely (Fig. 5, Fig.6).
Conclusions
1. The pathogenic relationship between dental restorative
materials causing reactions and oral lichenoid lesions, found
in these patients, was confirmed. Several studies, mainly
Scandinavian, have shown the benefit of replacing restorations
in the healing process of lichenoid reactions. Complete healing
of lichenoid lesions after replacement of dental amalgam in
28/62 (42%) patients with positive patch tests results and 3/15
(20%) with negative patch test results was reported by Laine et
al. (8). Bolewska et al. (1) gave information about the details
and the benefits of the replacement of amalgam restorations
1875
with resin composite and porcelain fused gold crowns, or the
prevention of contact between amalgam restorations and the
oral mucosa by an acrylic splint.
Fig. 4. Positive patch tests of the restorative materials in the mouth
Fig. 5. Condition of the tongue mucosa two months after replacing the
allergens- dorsal view
Fig. 6. Condition of the tongue mucosa two months after replacing the
allergens- ventral view
1876
A close contact to amalgam fillings causes the occurrence
of lichenoid reactions that are clinically and histologically
very similar to lichen planus but the etiology of the first one is
well determined. These oral lesions are probably the result of
allergic reaction to leaking products (11).
2. The patch test detection method is able to demonstrate
and prove the patient’s hypersensitivity to dental restorative
materials. Patch testing when used properly often provides
support for the diagnosis of allergic contact dermatitis (9).
Patch test is considered able to show whether there is a risk
of contact allergy reactions occurrence if certain materials are
used in a particular patient (3).
On the opposite opinion are Issa Y. et al., which consider
that a patch test seems to be of limited benefit as a predictor of
such reactions (4, 5).
3. The intraoral allergens are to blame for the found
lichenoid lesions.
4. The replacement of dental restorative materials with
hypoallergenic ones led to disappearing of the symptoms of
lichenoid lesions.
The adverse reaction from a dental restorative material can
be either toxic/irritative or allergic in nature. Therefore the
etiology of OLLs may represent the oral manifestation of a
chronic irritation in some patients or to be the clinical result of
a delayed hypersensitivity reaction in others. Allergic contact
lesions represent a lymphocyte-mediated delayed type of
hypersensitivity reaction that requires previous sensitization to
the same material (3). In a study of Massone et al. (10) was
found that nickel, cobalt, and potassium dichromate were the
three most common sensitizers. Concomitant positive reactions
were present at significant levels.
OLL may be provoked by dental restorations and the
diagnosis depends mainly on the clinical findings including
the lesion’s characteristics and relationship to restorations (3).
Amalgam restorations with their mercury content also appear
to be a major etiological factor.
5. One of the most important aspects of these lesions is
their premalignant potential. A prospective follow-up study
with application of strict criteria (including registration of
tobacco and alcohol consumption) and long term follow up
(not less than 5 years) is required to establish the premalignant
nature of OLP and OLL (13).
Certain OLP and OLL undergo malignant transformation
but the mechanisms are still unclear and controversial.
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